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{{Short description|Medical condition that started before a person's health benefits went into effect}}
{{about|the term in health insurance|medical use of the term|Complication (medicine)}}
{{Multiple issues|
{{lead too short|date=March 2014}}
{{Globalize|1=article|2=United States|date=January 2020}}
In the context of [[healthcare in the United States]], a '''pre-existing condition''' is a medical condition that started before a person's [[Health benefits (insurance)|health benefits]] went into effect. Before 2014 some insurance policies would not cover expenses due to pre-existing conditions. These exclusions by the [[insurance industry]] were meant to cope with [[adverse selection]] by potential customers. Such exclusions are prohibited after January 1, 2014, by the [[Patient Protection and Affordable Care Act]].▼
}}
{{Use mdy dates|date=August 2022}}
▲In the context of [[healthcare in the United States]], a '''pre-existing condition''' is a [[medical condition]] that started before a person's [[Healthhealth benefits (insurance)|health benefits]] went into effect. Before 2014, some insurance policies would not cover expenses due to pre-existing conditions. These exclusions by the [[insurance industry]] were meant to cope with [[adverse selection]] by potential customers. Such exclusions arehave been prohibited aftersince January 1, 2014, by the [[Patient Protection and Affordable Care Act]].
 
According to the [[Kaiser Family Foundation]], more than a quarter of adults below the age of 65 (approximately 52 million people) had pre-existing conditions in 2016.
 
== Definitions ==
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Conditions can be broken down into two further categories, according to Lisa Smith of [[Investopedia]]:<ref name="smith"/>
 
{{ quoteblockquote
| Most insurance companies use one of two definitions to identify such conditions. Under the "objective standard" definition, a pre-existing condition is any condition for which the patient has already received medical advice or treatment prior to enrollment in a new medical insurance plan. Under the broader, "prudent person" definition, a pre-existing condition is anything for which symptoms were present and a prudent person would have sought treatment.
}}
 
Which definition may be used was sometimes regulated by state laws. Some states required insurance companies to use the objective standard, while others required the prudent person standard. 10 states did not specify either definition, 21 required the "prudent person" standard, and 18 required the "objective" standard.<ref name="statehealthfacts"/>
 
According to the Kaiser Family Foundation, more than a quarter of adults below the age of 65 (approximately 52 million people) had pre-existing conditions in 2016.<ref name=":0">{{Cite news|url=https://www.npr.org/sections/health-shots/2018/10/11/656503264/fact-check-whos-right-about-protections-for-pre-existing-conditions|title=FACT CHECK: Who's Right About Protections For Pre-Existing Conditions?|work=NPR.org|access-date=October 12, 2018|language=en|date=October 11, 2018|author=Julie Rovner}}</ref>
 
== Current U.S. federal regulation ==
 
; [[Patient Protection and Affordable Care Act]] (Pub.L. 111-148111–148) enacted March 23, 2010<ref name="side-by-side"/>
* Immediate reform: effective June 21, 2010 (90 days after enactment)
** National high-risk pool for individuals with a pre-existing condition who have been uninsured for the prior 6 months
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** 6 months: 50 states + DC
 
Pre-existing condition exclusions were prohibited for HIPAA-eligible individuals (those with 18 months continuous coverage unbroken for no more than 63 days and coming from a group health insurance plan).
 
Individual (non-group) health insurance plans could exclude maternity coverage for a pre-existing condition of pregnancy.<ref name="jacobson" />
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== Practice and effect ==
 
Advocates against pre-existing condition rules argue that they cruelly deny needy people in need of treatment. [[State Farm]] spokeswoman K.C. Eynatten has said, "We realized our position was based on gut feelings, not hard numbers... we became aware that we were part of the reason a woman and her children might not leave an abuser. They were afraid they'd lose their insurance. And we wanted no part of that."<ref name="grim" /> Jerry Flanagan, health-care policy director of [[Consumer Watchdog]], has stated that "insurance companies want premiums without any risk" and go to extreme "lengths... to go to make a profit".<ref name="hilzenrath" /> [http://allinsuranceinfo.org/ InsureMe], an insurance quote provider website, has argued that even though health insurance is basically to protect people from very high costs of health care, the commercial health insurance system is not playing fair and are always trying to avoid risk in order to boost their profits.<ref name="allinsuranceinfo"/>
 
Some practices by some [[health insurance]] companies, such as determining [[domestic violence]] to be an excludable pre-existing condition, have been called abuses by Maria Tchijov, a [[Service Employees International Union]] new media coordinator, and by an [[Office of Rural Health Policy]] report.<ref name="grim"/><ref name="johnson"/><ref name="tchijov"/>
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== Public opinion ==
 
A ''[[Time Magazine(magazine)|Time]]''-Abt SRBI poll in late July 2009 found that a large majority of Americans (80%) favored a requirement that insurance companies insure people even if they suffer fromhave pre-existing conditions.<ref name="Abt SRBI" />
 
In September 2009, the monthly [[Kaiser Family Foundation|Kaiser Health Tracking Poll]] report said:<ref name="KFF tracking poll" />
 
{{blockquote
{{quote
| The public’spublic's most unanimous and bipartisan support is saved for a proposal to have the federal government require that health insurance companies cover anyone who applies, even if he/she has a pre-existing condition. Overall, eight in ten back the proposal, including 67 percent of Republicans, 80 percent of political independents and 88 percent of Democrats.
}}
 
== See also ==
 
* [[Pre-existing Condition Insurance Plan]]
 
== References ==
 
{{reflistReflist|30em|refs=
<ref name="Abt SRBI">{{cite web | date=July 29, 2009 |url=https://web.archive.org/web/20100915000000*/http://www.srbi.com/TimePoll4794_Final_%20Report.pdf |title=TIMETime magazine/Abt SRBI&nbsp;— July 27–28, 2009 survey |location=New York |publisher=SRBI |accessdateaccess-date=September 21, 2009 |archive-url=https://web.archive.org/web/20110116075242/http://www.srbi.com/TimePoll4794_Final_%20Report.pdf |archive-date=January 16, 2011 |url-status=dead}}</ref>
<ref name="KFF tracking poll">{{cite web | date=September 29, 2009 |title=Kaiser Health Tracking Poll—September 2009: Public opinion on health care issues |url=http://www.kff.org/kaiserpolls/upload/7990.pdf |accessdateaccess-date=January 16, 2010 |location=Washington, D.C. |publisher=[[Kaiser Family Foundation]]}}</ref>
<ref name="UPMC">{{cite web | year=2010 |url=http://www.upmc.com/HOSPITALSFACILITIES/FINANCIAL-SERVICES/Pages/billing-terminology.aspx|accessdateaccess-date=January 16, 2010|location=Pittsburgh|publisher=[[University of Pittsburgh Medical Center]] (UPMC)|title=Billing terminology}}{{|url-status=dead link|archive-url=https://web.archive.org/web/20101003092545/http://www.upmc.com/HospitalsFacilities/financial-services/Pages/billing-terminology.aspx|archive-date=MayOctober 20173, 2010}}</ref>
<ref name="jacobson">{{cite news |author=Jacobson, Louis |date=August 18, 2009 |title=Pregnancy a 'pre-existing condition'? Yes, for some |publisher=[[St. Petersburg Times|PolitiFact.com]] |url=http://www.politifact.com/truth-o-meter/article/2009/aug/18/pregnancy-pre-existing-condition/|accessdateaccess-date=January 17, 2010}}</ref>
<ref name="smith">{{cite web |author=Smith, Lisa |date=February 16, 2009 |title=Health insurance: paying for pre-existing conditions |publisher=[[Investopedia]]|url=http://www.investopedia.com/articles/pf/09/covering-medical-costs.asp |accessdateaccess-date=January 17, 2010}}</ref>
<ref name="statehealthfacts">{{cite web|url=https://www.kff.org/other/state-indicator/individual-market-portability-rules/|title=Individual Market Portability Rules (Not Applicable to HIPAA Eligible Individuals)|date=July 21, 2014|access-date=March 8, 2019}}</ref>
<ref name="statehealthfacts">http://www.statehealthfacts.org/comparetable.jsp?typ=5&ind=355&cat=7&sub=87&sortc=2&o=a</ref>
<ref name="kassebaum-kennedy">{{cite journal |doi=10.1377/hlthaff.13.1.327 |author1=Gabel, Jon |author2=Liston, Derek |author3=Jensen, Gail |author4=Marsteller, Jill |date=Spring 1994 |title=The health insurance picture in 1993: some rare good news |journal=[[Health Affairs]] |volume=13 |issue=1 |pages=327–336 |url=http://content.healthaffairs.org/cgi/reprint/13/1/327.pdf |accessdateaccess-date=February 22, 2010 |pmid=8188152}}</ref>
<ref name="kassebaum-kennedy-2">{{cite web |author1=Kassebaum, Nancy Landon |author2=Kennedy, Edward M. |date=August 21, 1996 |title=Public Law 104-191. Health Insurance Portability and Accountability Act of 1996 (HIPAA) |location=Washington, D.C. |publisher=[[United States Government Printing Office|Government Printing Office]] |url=http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=104_cong_public_laws&docid=f:publ191.104.pdf |accessdateaccess-date=February 22, 2010|display-authors=etal}}</ref>
<ref name="atchkinson-fox">{{cite journal |doi=10.1377/hlthaff.16.3.146 |author1=Atchkinson, Brian K. |author2=Fox, Daniel M. |date=May–June 1997 |title=The politics of the Health Insurance Portability and Accountability Act |journal=[[Health Affairs]] |volume=16 |issue=3 |pages=146–150 |pmid=9141331 |url=http://content.healthaffairs.org/cgi/reprint/16/3/146.pdf |accessdateaccess-date=February 22, 2010}}</ref>
<ref name="nicholls-blumberg">{{cite journal |doi=10.1377/hlthaff.17.3.25 |author1=Nichols, Len M. |author2=Blumberg, Linda J. |date=May–June 1998 |title=A different kind of 'new federalism'? The Health Insurance Portability and Accountability Act of 1996 |journal=[[Health Affairs]] |volume=17 |issue=3 |pages=25–42 |url=http://content.healthaffairs.org/cgi/reprint/17/3/25.pdf |accessdateaccess-date=February 22, 2010 |pmid=9637965}}</ref>
<ref name="pollitz-tapay">{{cite journal |doi=10.1377/hlthaff.19.4.7 |author1=Pollitz, Karen |author2=Tapay, Nicole |author3=Hadley, Elizabeth |author4=Specht, Jalena |date=July–August 2000 |title=Early experience with 'new federalism' in health insurance regulation |journal=[[Health Affairs]] |volume=19 |issue=4 |pages=7–22 |url=http://content.healthaffairs.org/cgi/reprint/19/4/7.pdf |accessdateaccess-date=February 22, 2010 |pmid=10916957}}</ref>
<ref name="gabel-jensen">{{cite journal |author1=Gabel, Jon R. |author2=Jensen, Gail A. |author3=Hawkins, Samantha |date=March–April 2009 |title=Self-insurance in times of growing and retreating managed care |journal=[[Health Affairs]] |volume=22 |issue=2 |pages=202–210 |url=http://content.healthaffairs.org/cgi/reprint/22/2/202.pdf |doi=10.1377/hlthaff.22.2.202 |accessdateaccess-date=February 22, 2010 |pmid=12674423}}</ref>
<ref name="side-by-side">{{cite web | date=March 22, 2010 |title= Side-by-side comparison of major health care reform proposals |location=Washington, DC |publisher=[[Kaiser Family Foundation]] |url= http://www.crawfordadvisors.com/whitePapers/Kaiser%20-%20Focus%20on%20Health%20Care%20Reform.pdf}}</ref>
<ref name="FR 28 June 2010">{{cite journal |author=U.S. Department of Health and Human Services |date=June 28, 2010 |title=Patient Protection and Affordable Care Act; Requirements for Group Health Plans and Health Insurance Issuers Under the Patient Protection and Affordable Care Act Relating to Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections; Final Rule and Proposed Rule |journal=[[Federal Register]] |volume=75 |issue=123 |pages=37187–37241 |url=http://edocket.access.gpo.gov/2010/2010-15278.htm |accessdateaccess-date=July 26, 2010}}</ref>
<ref name="GHPI">{{cite web |author=[[Georgetown Health Policy Institute]] |author-link=Georgetown Health Policy Institute |date=January 2010 |title=Individual market portability rules (not applicable to HIPAA eligible individuals), January 2010 |location=Washington, D.C. |publisher=[[Kaiser Family Foundation]] |url=http://www.statehealthfacts.org/comparemaptable.jsp?ind=355&cat=7&sub=87&yr=138&typ=5 |accessdateaccess-date=March 31, 2010}}</ref>
<ref name="GHPI-2">{{cite web |author=[[Georgetown Health Policy Institute]] |author-link=Georgetown Health Policy Institute |date=January 2010 |title=Non-group coverage rules for HIPAA eligible individuals, January 2010 |location=Washington, D.C. |publisher=[[Kaiser Family Foundation]] |url=http://www.statehealthfacts.org/comparemaptable.jsp?ind=356&cat=7&sub=87&yr=138&typ=5 |accessdateaccess-date=March 31, 2010}}</ref>
<ref name="GHPI-3">{{cite web |author=[[Georgetown Health Policy Institute]] |author-link=Georgetown Health Policy Institute |date=January 2010 |title=Small group health insurance market pre-existing condition exclusion rules, January 2010 |location=Washington, D.C. |publisher=[[Kaiser Family Foundation]] |url=http://www.statehealthfacts.org/comparemaptable.jsp?ind=352&cat=7&sub=86&yr=138&typ=5 |accessdateaccess-date=March 31, 2010}}</ref>
<ref name="grim">{{cite news|url=http://www.huffingtonpost.com/2009/09/14/when-getting-beaten-by-yo_n_286029.html|accessdateaccess-date=September 19, 2009|publisherwork=[[The Huffington Post]]|title=When getting beaten by your husband is a pre-existing condition|first=Brian|last=Grim|date=September 14, 2009}}</ref>
<ref name="hilzenrath">{{cite news|url=httphttps://www.washingtonpost.com/wp-dyn/content/article/2009/09/18/AR2009091803501.html|title=Acne, pregnancy among disqualifying conditions|date=September 19, 2009|accessdateaccess-date=January 16, 2010|first=David S.|last=Hilzenrath|newspaper=[[The Washington Post]] |page=A3}}</ref>
<ref name="allinsuranceinfo">{{cite web | year=2007 |url=http://allinsuranceinfo.org/health/tricks.html |title=Health insurance tricks to beware of|accessdateaccess-date=January 20, 2010|publisher=allinsuranceinfo.org}}</ref>
<ref name="johnson">{{cite web |author=Johnson, Rhonda M. |date=August 30, 2000 |title=Rural health response to domestic violence: policy and practice issues |url=http://ruralhealth.hrsa.gov/pub/domviol.htm |location=Washington, D.C. |publisher=[[Office of Rural Health Policy]] |accessdateaccess-date=September 15, 2009 |archive-url=https://web.archive.org/web/20090425174825/http://ruralhealth.hrsa.gov/pub/domviol.htm |archive-date=April 25, 2009 |url-status=dead }}</ref>
<ref name="tchijov">{{cite web|author=Tchijov, Maria |url=http://www.seiu.org/2009/09/domestic-violence-victims-have-a-pre-existing-condition.php|title=Domestic violence is a 'pre-existing condition'? |work=SEIU Blog |publisher=[[Service Employees International Union]]|accessdateaccess-date=September 15, 2009|date=September 11, 2009|archive-url=https://web.archive.org/web/20090916025852/http://www.seiu.org/2009/09/domestic-violence-victims-have-a-pre-existing-condition.php|archive-date=September 16, 2009|url-status=dead}}</ref>
<ref name="chronicle">{{cite news|url=http://articles.sfgate.com/2009-11-17/news/17182067_1_health-care-health-insurance-pre-existing-medical-problem |newspaper=[[San Francisco Chronicle]]|date=November 17, 2009|accessdateaccess-date=January 16, 2010|title=Americans fear health law's costs poll finds|author1=Ricardo Alonso-Zaldivar|author2=Trevor Tompson}}{{dead link|date=May 2017}}</ref>
<ref name="alonso-zaldivar">{{cite news|url=http://articles.sfgate.com/2009-11-17/news/17182067_1_health-care-health-insurance-pre-existing-medical-problems|newspaper=[[San Francisco Chronicle]] |page=A118 |date=November 17, 2009|accessdateaccess-date=January 16, 2010|title=Americans fear health law's costs poll finds|author=Alonso-Zaldivar, Ricardo |author2=Tompson, Trevor |agency=Associated PresPress)}}</ref>
<ref name="pledge">{{cite web|author=Suderman, Peter (opinion blog)|date=September 23, 2010|title=What the GOP's Pledge has in common with ObamaCare|work=Hit and Run|publisher=[[Reason (magazine)|Reason]]|url=http://reason.com/blog/2010/09/23/what-the-gops-pledge-has-in-co|accessdateaccess-date=September 23, 2010}}</ref>
<ref name="marketwatch">http{{cite web|title=Text of President Obama's health-care speech |url=https://www.marketwatch.com/story/full-text-of-president-obamas-health-care-speech-2010-03-03 |access-date=September 15, 2018 |date=March 3, 2010}}</ref><ref name="aizenman-kornblut">{{cite news| url=https://www.washingtonpost.com/wp-dyn/content/article/2010/09/22/AR2010092205365.html | newspaper=The Washington Post | first1=N. C. | last1=Aizenman | first2=Anne E. | last2=Kornblut | title=Obama returns to stump for health care | date=September 23, 2010}}</ref>
<ref name="aizenman-kornblut">{{cite news| url=http://www.washingtonpost.com/wp-dyn/content/article/2010/09/22/AR2010092205365.html | work=The Washington Post | first1=N. C. | last1=Aizenman | first2=Anne E. | last2=Kornblut | title=Obama returns to stump for health care | date=September 23, 2010}}</ref>
}}
 
==Further reading==
* {{cite web | author=Timm, Jane C. | title=Fact check: Trump claims GOP is protecting people with pre-existing conditions. Evidence says otherwise. | publisher=[[NBC News]] | date=October 23, 2018 | url=https://www.nbcnews.com/politics/elections/fact-check-trump-claims-gop-protecting-people-pre-existing-conditions-n923056 | access-date=March 8, 2019}}
* {{cite web | author=Pear, Robert | title=Democrats Unite to Begin Push to Protect Pre-Existing Condition Coverage | website=[[The New York Times]] | date=February 6, 2019 | url=https://www.nytimes.com/2019/02/06/us/politics/democrats-pre-existing-condition-coverage.html | access-date=March 8, 2019}}
* Lovelace, Berkeley Jr. & Breuninger, Kevin (September 24 2020). [https://www.cnbc.com/2020/09/24/trump-to-sign-executive-orders-on-preexisting-conditions-surprise-medical-billing.html "Trump to sign executive orders protecting preexisting conditions and seeking a way to prevent surprise medical bills"]. [[CNBC]].
 
[[Category:Health insurance in the United States]]
[[Category:Insurance law]]
[[Category:Health policy]]
[[Category:InsuranceSocial termsproblems in medicine]]
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